Q&A: Dr. Medha Munshi of the Geriatric Diabetes Clinic

Friday, May 27, 2011

Working both as a geriatrics primary care physician and as head of Joslin’s Geriatric Diabetes Clinic gives Medha Munshi, M.D., a different perspective on how to manage diabetes in the elderly population. While most diabetes management emphasizes the complexity of the disease, these patients often benefit from keeping things simple, Dr. Munshi declares. Here she answers seven questions about diabetes management in the elderly and why A1C levels may not always provide the best guidelines.

Was there a model for geriatric diabetes care when you started the clinic here in 2001?

No. Even right now, I don’t know of any clinical model to take care of geriatric patients with diabetes. It is quite surprising considering the number of patients who are aging and how many more we’re going to see.

I began by going to the Joslin pediatrics clinic and talking with them. I think my patients are very similar to their patients in the sense that things other than their health affect their diabetes management. All kids have at least one parent; lots of my patients have nobody. Unless their environment is considered, they can’t do what we ask them to do.

I also started putting my patient data into Joslin’s electronic medical records system and screening patients for problems that I thought were interfering with their self care.

What patterns did you start to see?

In geriatrics, you see these older patients who are taking care of themselves. That’s the best part of geriatrics, right? With a 40-year-old, I can’t judge if they are doing what they are supposed to do. With my patients, I know that they are trying their best. Otherwise they wouldn’t be here! If they are failing then the benefit of doubt goes to them. So, we try to find other reasons why they are not doing well and often, something else is going on that is not letting them do what they are trying to do.

We also found that health in these patients is very dynamic. Someone who is really doing well today may have a decline in their health for other reasons, which will impact their ability to take care of their diabetes very quickly. Some of these patients have caregivers and other don’t and that makes a big difference.

Is memory the biggest problem for some elderly patients?

The cognitive issues aren’t just about memory. What I saw in my patients was that often they remembered what I asked them to do. I would talk to them and say, Let’s do this, and they would say, OK, repeat it, and go back home. They would come back in three months and nothing would have changed. And I’d say, Didn’t we talk about it? They would remember and they would promise to do it. They would go home, they would come back and they would not have done it.

I started talking to Dr. William Milberg, who is a neuropsychologist at the Veterans Administration and Harvard Medical School. His specialty is executive dysfunction in patients with cardiovascular risk factors. What he had found, and what is now really well understood, is that the brain’s frontal lobe—which controls high-functioning behavior like integrating information, problem-solving, stopping old behavior and starting new behavior—may be affected by chronic diseases like diabetes and hypertension. In many instances, memory component is not as much affected.

It’s really subtle. People with this kind of deficit may go on and live their lives without anyone knowing that they have a problem. They can do what they’ve been doing for many years, but if they are given a new complicated task, they fall apart. For them, the biggest issue is change and their capacity to cope with it.

What other difficulties crop up?

The other issue that goes along with that is depression. People who are depressed can’t do the best self-management and prevent long-term complications; they just don’t have that kind of attitude.

And then there are physical disabilities, such as vision loss and hearing loss. And other diseases, either related to diabetes or not, that are being treated by multiple medications for most of the patients in this age group.

In addition, many have adverse social situations where they might be caring for a spouse or other family members, or have limited finances or difficulty with transportation, etc. When older adults are in good health, many manage well. But even these people are put in a very difficult situation when they get sick and cannot take care of themselves.

How do they deal with all of that?

Trying to put everything together sometimes becomes impossible for them.

For physicians, diabetes makes us think about microvascular and macrovascular disease, foot problems and kidney problems and eye problems. It doesn’t make us think about these issues.

So consultants often don’t think about them. They give these patients regimens that are essentially beyond their coping skills.

What have you learned from your clinical research?

In the clinic, we identify the barriers to self-care. When we see a new patient, we can use very short interview tools to understand the patient’s background. We look for cognitive problems, depression, health literacy, nutrition literacy, social support structure, medications and adherence to medications.

Then we try to help with the barriers that can be modified, like depression or social isolation.

You can’t reverse certain barriers like cognitive dysfunction and physical disabilities. So we modify our regimen for those, so that that it can fit their social and clinical and functional background and they now can cope with it. That’s the biggest philosophical difference in management at our geriatric clinic.

The biggest problems we get are the cognitive problems. Patients may be doing fine on their own in general but they forget to take their insulin injections or they are making errors in how much dose they are supposed to take or they forget to eat on time and get hypoglycemic. So what we do is simplify things. Maybe four injections a day is not practical and two injections a day will work better. Or perhaps if they live with someone, they can do their procedures before the caregiver leaves home and when they come back, to offer a little more supervision.

All the algorithms in diabetes management are about how do you increase the complexity. But for some patients, we are now developing an algorithm that is exactly reversed—the patient has a complicated insulin regimen, and how can we simplify that?

How does that affect their long-term health?

Hypoglycemia (low blood glucose) is the biggest and most dangerous aspect of diabetes management in older patients. I don’t think people pay enough attention to it.

One reason for that is that there is no good measure for hypoglycemia. Older patients may not always feel hypoglycemia. We need a reverse A1C that can measure the collective hypoglycemia. Continuous glucose monitoring (CGM) can do it but only for three days.

Often hypoglycemia is completely ignored as it is difficult to identify, but we know that hypoglycemia is not okay, especially for this population. A 20-year-old can pass out and fall and get up and go. An 80-year-old may end up in a nursing home and lose their independence. It’s just not logical to treat them in the same way.

In February we published, in The Archives of Internal Medicine, a study in which we performed CGM on patients 70 years and older with poor glycemic control. What we found is that when you have a high A1C it’s not that the blood sugars are very high as opposed to more normal. The blood sugars are all over the place. The patients are getting multiple hypoglycemic episodes. Sixty percent of our test population of 40 people, with A1Cs of 8 or 9, had at least one number below 70 during the three-day test period.

When you simplify things, the frequency of hypoglycemia episodes not only gets less but A1Cs actually improve, because patients now are actually doing what they’re supposed to do and not constantly chasing their blood sugars. Their quality of life improves, they feel better and their A1Cs drop.

Physicians need some flexibility to look at the patient and not just the numbers such as A1Cs and blood pressure. For many of these patients, it’s okay to not hit those numbers, as long as you do it purposefully. Rather than an A1C, the goal should be the best blood glucose numbers you can get without the risk of hypoglycemia. Starting with that might be the best step we can take for those patients.